Nonoperative Therapy
Most stress fractures can be treated conservatively by having patients stop or significantly decrease their activity for approximately 4-6 weeks, then gradually return to activity. [47, 48] (See Table 3 below.) Patients who experience pain with walking may be placed in a short leg cast with crutches, a walking boot, or a brace for 4-6 weeks. The use of pneumatic braces in the treatment and rehabilitation of tibial stress fractures also speeds the patient's return to training. [49]
Table 3. Healing Times for Various Stress Fractures* [47] (Open Table in a new window)
Site of Stress Fracture |
Percentage Healed at 2-4 wk, % |
Percentage Healed at 1-2 mo, % |
Percentage Healed at > 2 mo, % |
Tibia, proximal third |
0 |
43 |
57 |
Tibia, middle third |
0 |
48 |
52 |
Tibia, distal third |
0 |
53 |
47 |
Fibula |
7 |
75 |
18 |
Metatarsals |
20 |
57 |
23 |
Sesamoids |
0 |
0 |
100 |
Femur, shaft |
7 |
7 |
86 |
Femur, neck |
0 |
0 |
100 |
Pelvis |
0 |
29 |
75 |
Olecranon |
0 |
0 |
100 |
*Adapted from Hulkko et al. [48] Findings were from a case series of 368 stress fractures in athletes, in which the healing times of stress fractures in different locations were assessed. |
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Surgical Care
Surgery for high-risk stress fractures
Nonunion of stress fractures is uncommon but can occur. These injuries should be closely followed up for early surgical intervention. High-risk stress fractures include stress fractures of the neck of the femur, [4] the anterior cortex of the tibia, the tarsal navicular, and the bases of the second and fifth [50] metatarsals. [47] Other high-risk stress fractures are stress fractures of the patella and medial malleolus. [51] Anterior-cortex stress fractures of the tibia are considered high-risk because the tensile forces across the anterior portion of the tibia can typically lead to delayed union or nonunion.
In contrast, low-risk stress fractures include most upper-extremity stress fractures, with the possible exception of fractures through the physis of the humeral head (Little League shoulder) and fractures through the medial epicondyle (Little League elbow), which may have complications due to the involvement of the growth plate. Other low-risk fractures include stress fractures of the ribs, pelvis, femoral shaft, fibula, calcaneus, and metatarsal shafts.
Prevention
Nutritional measures
Regarding fracture risk, Schwellnus and Jordaan found no benefit with calcium supplementation (500 mg/day) beyond the usual dietary intake in male military recruits. [52]
Biomechanical measures
The use of orthotic devices and shoe inserts has been studied as a preventive measure for lower-extremity stress fractures. Finestone and Milgrom both studied the use of semirigid orthoses, soft orthoses, or both in the boots of military recruits during basic training. [53, 54]
Finestone found that the incidence of lower-extremity stress fractures was lower in the group using semirigid orthoses (15.7%) or soft biomechanical orthoses (10.7%) than in the control group (27%). [53] Additionally, the recruits tolerated the soft biomechanical orthoses better than they did the semirigid orthoses.
In a prospective study of stress fractures, Milgrom et al studied the hypothesis that a shock-absorbing orthotic device worn within military boots decreases the incidence of stress fractures. [54] They demonstrated a statistically significant decrease in the incidence of femoral stress fractures in the orthotic device group. In military recruits who did develop stress fractures, the time of onset and the location of stress fractures did not differ between patients who wore the orthotic device and those who did not.
Gillespie and Grant reviewed the use of shock-absorbing insoles in four trials. [49] These insoles appeared to reduce the incidence of stress fractures and stress reactions of bone; however, incomplete data from one trial indicated that a reduction in the running distance and intensity may also have been a factor in preventing stress fractures.
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Fifth metatarsal stress fracture.
Tables
Location of Fracture |
Activity Involved |
Metatarsals, general |
Football, basketball, gymnastics, ballet, military training [25] |
Metatarsal, base of the second |
Ballet |
Metatarsal, fifth |
|
Sesamoids of the foot |
Running, ballet, basketball, skating |
Navicular |
Sprinting, [28] jumping, basketball, football |
Talus |
Pole vaulting |
Calcaneus |
Military drills, running, aerobics |
Fibula |
Running, jumping, ballet, repeated heavy lifting [28] |
Tibia |
Running sports, dancing, ballet |
Patella |
Running, hurdling |
Femoral neck |
Distance running, military training [29] |
Pubic rami |
Military drills, distance running |
Pars articularis |
Gymnastics, ballet, cricket, volleyball, diving, football |
Chest, ribs |
Swimming, [30] golf, [31] rowing, [32] overhead throwing sports [33] |
Sternum |
Wrestling [34] |
Ulna |
Racquet sports, volleyball |
Olecranon |
Baseball, throwing sports |
Grade |
Radiographic Finding |
Bone Scan Finding |
MRI Finding |
1 |
Normal |
Poorly defined area |
Increased activity on STIR image |
2 |
Normal |
More intense |
Poor definition on STIR and T2-weighted images |
3 |
Discrete line |
Sharp area of uptake |
No focal or fusiform cortical break on T1- and T2-weighted images |
4 |
Fracture or periosteal reaction |
More intense localized transcortical uptake |
Fracture line on T1- and T2-weighted images |
Site of Stress Fracture |
Percentage Healed at 2-4 wk, % |
Percentage Healed at 1-2 mo, % |
Percentage Healed at > 2 mo, % |
Tibia, proximal third |
0 |
43 |
57 |
Tibia, middle third |
0 |
48 |
52 |
Tibia, distal third |
0 |
53 |
47 |
Fibula |
7 |
75 |
18 |
Metatarsals |
20 |
57 |
23 |
Sesamoids |
0 |
0 |
100 |
Femur, shaft |
7 |
7 |
86 |
Femur, neck |
0 |
0 |
100 |
Pelvis |
0 |
29 |
75 |
Olecranon |
0 |
0 |
100 |
*Adapted from Hulkko et al. [48] Findings were from a case series of 368 stress fractures in athletes, in which the healing times of stress fractures in different locations were assessed. |
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